1. ACSM’s Updated Recommendations for Exercise Preparticipation Health Screening
Moderator: Carol Ewing Garber, Ph.D., FACSM, Columbia University
Presenter: Linda S. Pescatello, Ph.D., FACSM, University of Connecticut
Presenter: Deborah Riebe, Ph.D., FACSM, University of Rhode Island

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3. Updating the ACSM Recommendations for Exercise Preparticipation Health Screening
Discuss the current American College of Sports Medicine’s (ACSM) exercise preparticipation health screening recommendations
American College of Sports Medicine’s (ACSM) Guidelines for Exercise Testing and Prescription the Ninth Edition (GETP 9)
Discuss the new ACSM exercise preparticipation health screening recommendations
Medicine Science Sports & Exercise in November 2015: Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise pre-participation health screening. Med Sci Sports Exerc, 2015; 47(11):
ACSM GETP10 in 2017
Apply the new ACSM exercise preparticipation health screening recommendations to a case study

4. ACSM’s Exercise Preparticipation Health Screening
To identify individuals who may be at risk for serious acute exercise-related cardiovascular events including sudden cardiac death and myocardial infarction
Vigorous intensity exercise does have a small but measureable acute risk of CVD complications; mitigating this risk in susceptible individuals is important

5. Updating the ACSM Recommendations for Exercise Preparticipation Health Screening
Discuss the current American College of Sports Medicine’s (ACSM) exercise preparticipation health screening recommendations
American College of Sports Medicine’s (ACSM) Guidelines for Exercise Testing and Prescription the Ninth Edition (GETP 9)
Discuss the new ACSM exercise preparticipation health screening recommendations
Medicine Science Sports & Exercise in November 2015: Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise pre- participation health screening. Med Sci Sports Exerc, 2015; 47(11):
ACSM GETP10 in 2017
Apply the new ACSM exercise preparticipation health screening recommendations to a case study

6. The Current ACSM Exercise Preparticipation Health Screening Recommendations
All people wanting to initiate a physical activity program should be screened at minimum by a self-guided medical history or health risk appraisal questionnaire such as the PAR-Q or modified American Heart Association / ACSM Health/Fitness Facility Preparticipation Screening Questionnaire for the presence of risk factors for cardiovascular, pulmonary, renal, and metabolic diseases as well as other conditions (e.g., pregnancy and orthopedic injury) that require special attention when designing the exercise prescription (Ex Rx)
ACSM GETP 9

7. The Current ACSM Exercise Preparticipation Health Screening Recommendations
Individuals are classified as low, moderate, or high risk based on the presence or absence of:
Cardiovascular disease (CVD) risk factors
Signs and symptoms of cardiovascular, pulmonary, renal, or metabolic disease
Known cardiovascular, pulmonary, renal, or metabolic disease
ACSM GETP 9

8. ACSM GETP 9

9. ACSM GETP 9 FIGURE 2. 3. Logic model for classification of risk
ACSM GETP 9 FIGURE 2.3. Logic model for classification of risk. CV, cardiovascular; CVD, cardiovascular disease.

10. ACSM GETP 9 FIGURE 2.4. Medical examination, exercise testing, and supervision of exercise testing preparticipation recommendations based on classification of risk. Ex Rx, exercise prescription; HR, heart rate; METs, metabolic equivalents; VO2R, oxygen uptake reserve.

11. The Current ACSM Exercise Preparticipation Health Screening Recommendations
Individuals at moderate risk with >2 CVD risk factors should be encouraged to consult with their physician prior to initiating a vigorous intensity, physical activity program
While medical evaluation is taking place, the majority of these people can begin light to moderate intensity, physical activity programs such as walking without consulting a physician
Individuals at high risk with symptoms or diagnosed disease should consult with their physician prior to initiating a physical activity program
ACSM GETP 9

12. ACSM GETP 9, NCEP ATP III, ADA Diabetes Care 2007, JNC 7

13. The Current ACSM Exercise Testing Recommendations
Routine exercise testing before initiating a vigorous intensity, physical activity program is recommended only for individuals at high risk of exercise-related complications

14. The Current ACSM Exercise Preparticipation Health Screening Recommendations
Compared to the previous ACSM recommendations, the current ACSM exercise preparticipation health screening recommendations:
More strongly support the public health message that all people should adopt a physically active lifestyle
Reduce the emphasis on the need for medical evaluation in healthy, asymptomatic persons
Emphasize identifying those with known disease because they are at greatest risk for an exercise-related cardiac event
Simplify the exercise preparticipation health screening process

15. Why Reevaluate the Current ACSM Exercise Preparticipation Health Screening Recommendations?
Exercise is safe for most people and has many health/fitness benefits
The cardiovascular risks associated with exercise lessen as individuals become more physically active/fit
Exercise-related cardiovascular events are rare and often are preceded by warning signs and symptoms
The current prescreening algorithms can result in excessive referrals to physicians for medical clearance
Potential barrier to adopting exercise
Financial burden on the individual and health care system

16. ACSM Scientific Roundtable: Updating Recommendations for Exercise Preparticipation Health Screening
Expert panel was convened by ACSM in June 2014 to establish best practices in the exercise preparticiaption health screening practice
Experts in risk assessment, preventive cardiology, public health, exercise physiology, and geriatrics
Practitioners from the field of medicine, clinical exercise physiology, and health fitness/prevention
David M. Buchner, M.D., M.P.H., FACSM
JoAnn Eickhoff-Shemek, Ph.D., FACSM
Carol Ewing Garber, Ph.D., FACSM
Barry A. Franklin, Ph.D., FACSM
Adrien Hutber, Ph.D.
Elizabeth A. Joy, M.D., M.P.H., FACSM
Gary Liguori, Ph.D., FACSM
Meir Magal, Ph.D., FACSM
Linda S. Pescatello, Ph.D., FACSM
Deborah Riebe, Ph.D., FACSM
Thomas Spring, M.S.
Paul D. Thompson, M.D., FACSM
Darren E.R. Warburton, Ph.D.
Geoffrey P. Whitfield, Ph.D.
Walter R. Thompson, Ph.D., FACSM

17. Why Reevaluate the Current ACSM Exercise Preparticipation Health Screening Recommendations?
Exercise is safe for most people and has many health/fitness benefits
Cardiovascular risks associated with exercise lessen as individuals become more active/fit
Exercise-related cardiovascular events are rare and often preceded by warning signs and symptoms
The current prescreening algorithms can result in excessive referrals to physicians for medical clearance
Potential barrier to adopting exercise
Financial burden on the individual and health care system

18. Relative Risk of Acute Vigorous Intensity Exercise
ACSM GETP ; AHA Scientific Statement. Circulation 2007

19. Absolute Risk of Acute Vigorous Intensity Exercise is Low
Study / Population
Prevalence of SCD and/or MI
Physicians’ Health Study (men)
1 in every 1.5 million episodes of vigorous activity
Nurses’ Health Study (women)
1 in every 36.5 million hours of moderate or vigorous exercise
Joggers in RI
1 death per 396,000 hours of jogging
YMCA participants
1 death per 2,897,057 person-hours of exercise
Marathon and half-marathon runners
0.20 cardiac arrests and 0.14 SCD per 100,00 runner-hours
Supervised Cardiac Rehabilitation Programs
1 cardiac arrest per 116,906 patient-hr, 1 fatality per 752,365 patient-hr, and 1 major complication per 81,670 patient-hr of exercise participation
ACSM GETP 9, Thompson JAMA 1982; Siscovick NEJM 1984; AHA Scientific Statement Circulation 2007

20. Exercise Is Safe!
The relative risk of a cardiovascular event is increased during vigorous intensity exercise relative to rest, but the absolute risk of a cardiac event is low

21. Exercise is safe for most people and has many health/fitness benefits
Why Reevaluate the Current ACSM Exercise Preparticipation Health Screening Recommendations?
Exercise is safe for most people and has many health/fitness benefits
Cardiovascular risks associated with exercise lessen as individuals become more active/fit

22. Rest
ACSM GETP 9, Mittleman NEJM 1993; AHA Scientific Statement. Circulation 2007

23. Dahabreh IJ, Paulus JK. JAMA 2011;305(12):1225-1233
Conclusion: Acute cardiac events were significantly associated with episodic physical activity; this association was significantly attenuated among persons with high levels of habitual physical activity.
Dahabreh IJ, Paulus JK. JAMA 2011;305(12):

24. Dahabreh IJ, Paulus JK. JAMA 2011;305(12):1225-1233

25. Exercise is safe for most people and has many health/fitness benefits
Why Reevaluate the Current ACSM Exercise Preparticipation Health Screening Recommendations?
Exercise is safe for most people and has many health/fitness benefits
Cardiovascular risks associated with exercise lessen as individuals become more active/fit
Exercise-related cardiovascular events are rare and often preceded by warning signs and symptoms

26. Signs and Symptoms
Individuals who experience cardiovascular complications during or soon after exercise often have prodromal symptoms in the days and weeks before the event.
Exercise professionals should promote education about exertion-related symptoms in the persons they counsel
Franklin Circulation 2014; Thompson Circulation 2007

27. Why Reevaluate the Current ACSM Exercise Preparticipation Health Screening Recommendations?
Exercise is safe for most people and has many health/fitness benefits
Cardiovascular risks associated with exercise lessen as individuals become more active/fit
Exercise-related cardiovascular events are rare and often preceded by warning signs and symptoms
The current prescreening algorithms can result in excessive referrals to physicians for medical clearance
Potential barrier to adopting exercise
Financial burden on the individual and health care system

28. Whitefield Circulation 2014
Conclusion: > 90% of US adults aged ≥ 40 years would receive a recommendation for physician consultation by the AAPQ. Excessive referral may present an unnecessary barrier to exercise adoption and stress the healthcare infrastructure.
Whitefield Circulation 2014

29. Predictive Value of CVD Risk Factor Assessment is Low
The high prevalence of CVD risk factors among adults, combined with the extreme rarity of exercise-related SCD and AMI suggests that the ability to predict these rare events by assessing CVD risk factors is low
65 million US adults have hypertension and 71 million have high low density lipoprotein- cholesterol
In contrast, 600,00 people die from heart disease each year, and only a small fraction of those are due to exercise-associated SCD and AMI

30. Updating the ACSM Recommendations for Exercise Preparticipation Health Screening
Discuss the current American College of Sports Medicine’s (ACSM) exercise preparticipation health screening recommendations
American College of Sports Medicine’s (ACSM) Guidelines for Exercise Testing and Prescription the Ninth Edition (GETP 9)
Discuss the new ACSM exercise preparticipation health screening recommendations
Medicine Science Sports & Exercise in November 2015: Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise pre-participation health screening. Med Sci Sports Exerc, 2015; 47(11):
ACSM GETP 10 in 2017

31. The New ACSM Exercise Preparticipation Health Screening Recommendations
The expert panel:
Continues to encourage preparticipation screening for persons interested in initiating or progressing exercise or other physical activity programs
Recognizes that vigorous intensity exercise has a small but measurable acute risk of CVD complications and mitigating this risk in susceptible individuals is important
Continues to recommend that exercise professionals consult with health care providers when there are questions about individuals with known disease or signs and symptoms suggestive of disease, or any other concern about an individual’s ability to safely participate in an exercise program

32. The New ACSM Exercise Preparticipation Health Screening Recommendations
The new exercise preparticipation health screening recommendations are not a replacement for sound clinical judgment, and decisions about referral to a health care provider for medical clearance prior to the initiation of an exercise program should continue to be made on an individual basis

33. What’s New?
The expert panel proposed a new evidence-informed model for exercise preparticipation health screening based on three factors:
The individual’s current level of physical activity
Presence of signs or symptoms and/or known cardiovascular, metabolic, or renal disease
Desired exercise intensity

34. What’s New?
No longer includes the CVD risk factor profile as part of the decision making for referral to a health care provider prior to the initiating a moderate-to-vigorous intensity exercise program
No longer recommends a low/moderate/high risk classification scheme
Makes general recommendations for medical clearance versus specific recommendations for medical exams or exercise tests, leaving the manner of clearance to the discretion of the healthcare provider.
Does not automatically refer individuals with pulmonary disease for medical clearance prior to the initiation of an exercise program

36. Participates in Regular Exercise§No
No CV‡, Metabolic‡‡, or Renal Disease
AND
No Signs or Symptoms‡‡‡ Suggestive of CV‡, Metabolic‡‡, or Renal Disease
Known CV‡, Metabolic‡‡, or Renal Disease
AND
Asymptomatic
Any Signs or Symptoms‡‡‡ Suggestive of CV‡, Metabolic‡‡, or Renal Disease
(Regardless of disease status)
Medical Clearance‡‡‡‡ Not Necessary
Medical Clearance‡‡‡‡ Recommended
Medical Clearance‡‡‡‡ Recommended
Light to Moderate** Intensity Exercise Recommended
May Gradually Progress to Vigorous*** Intensity Exercise Following ACSM Guidelinesɸ
Following Medical Clearance, Light* to Moderate** Intensity Exercise Recommended
May Gradually Progress as Tolerated Following ACSM Guidelinesɸ
Following Medical Clearance, Light* to Moderate** Intensity Exercise Recommended
May Gradually Progress as Tolerated Following ACSM Guidelinesɸ

37. Participates in Regular Exercise§
Yes
No CV‡, Metabolic‡‡, or Renal Disease
AND
No Signs or Symptoms‡‡‡ Suggestive of CV‡, Metabolic‡‡, or Renal Disease
Known CV‡, Metabolic‡‡, or Renal Disease
AND
Asymptomatic
Any Signs or Symptoms‡‡‡ Suggestive of CV‡, Metabolic‡‡, or Renal Disease
(Regardless of disease status)
Medical Clearance‡‡‡‡ for Moderate Intensity Exercise Not Necessary
Medical Clearance (within the last 12 months if no change in signs/symptoms) Recommended Before Engaging in Vigorous*** Intensity Exercise
Medical Clearance‡‡‡‡ Not Necessary
Discontinue Exercise and Seek Medical Clearance
Continue Moderate** or Vigorous*** Intensity Exercise
May Gradually Progress Following ACSM Guidelinesɸ
May Return to Exercise Following Medical Clearance
Gradually Progress as Tolerated Following ACSM Guidelinesɸ
Continue with Moderate** Intensity Exercise
Following Medical Clearance, May Gradually Progress as Tolerated Following
ACSM Guidelinesɸ

38. Medical Clearance vs. Medical Exam and Exercise Test
Medical clearance has replaced specific recommendations for a medical exam or exercise test because it should be the health care provider that decides what evaluation, if any, is appropriate prior to the initiation of exercise
There is a lack of evidence that medical clearance and exercise testing are effective in mitigating the risk of exercise-related cardiovascular deaths

39. Current guidelines regarding exercise testing likely are not applicable to the majority of persons > 75 years who are interested in a program of physical activity / exercise. In addition to being expensive and of unproven benefit, the current policy of routine exercise testing potentially could deter many older persons from participating in an exercise program.
Gill JAMA 2000

40. The US Preventive Services Task Force found that screening exercise
testing had no value in low-risk asymptomatic adults and found insufficient evidence for or against testing in subjects at higher risk.

41. Lauer M et al. Circulation 2005
Randomized trial data on the clinical value of screening testing are absent; that is, it is not known whether a strategy of routine screening exercise testing in selected subjects reduces the risk for premature mortality or major cardiac morbidity.
Lauer M et al. Circulation 2005

42. Updating the ACSM Recommendations for Exercise Preparticipation Health Screening
Discuss the current American College of Sports Medicine’s (ACSM) exercise preparticipation health screening recommendations
American College of Sports Medicine’s (ACSM) Guidelines for Exercise Testing and Prescription the Ninth Edition (GETP 9)
Discuss the new ACSM exercise preparticipation health screening recommendations
Medicine Science Sports & Exercise in November 2015: Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise pre-participation health screening. Med Sci Sports Exerc, 2015; 47(11):
ACSM GETP10 in 2017
Apply the new ACSM exercise preparticipation health screening recommendations to a case study

43. Case Study
Louise is 55 yr old corporate executive who is 5’6” tall and weighs 145 lb (BMI 24.3 kg•m-2). She is a nonsmoker. Her father had a heart attack at 74 yr, her mother and one of her sisters have type 2 diabetes. Her blood pressure is 128/84 mmHg, total cholesterol is 218 mg•dL-1, LDL cholesterol is 141 mg•dL-1, HDL cholesterol 52 mg•dL-1, and fasting glucose is 122 mg•dL-1. She reports no signs/symptoms of chronic disease and no diagnosed cardiovascular, metabolic or renal disease. Louise has walked 4-5 d•wk-1 for years. She has recently received a job promotion and is having difficulty finding time to walk. Louise would like to join her fitness center at work so she can start walking at lunch or as her schedule permits.

44. The Current ACSM Exercise Preparticipation Health Screening Recommendations
# of Risk Factors
3 (age, dyslipidemia, prediabetes)
Signs and Symptoms No
Known Disease
Risk Classification
Moderate
Medical Exam Needed?
Moderate Exercise – No
Vigorous Exercise -
Exercise Test Needed?
Vigorous Exercise - No
Yes

45. The New ACSM Exercise Preparticipation Health Screening Recommendations
Participates in Regular Exercise
Yes
Signs and Symptoms No
Known Disease
Medical Clearance Needed?
Moderate Exercise - No
Vigorous Exercise - No

46. The New ACSM Exercise Preparticipation Health Screening Recommendations
Emphasizes the important public health message of regular physical activity for all
Simplifies the prescreening process by eliminating the need for medical clearance and/or exercise testing in many individuals, especially when low to moderate intensity exercise is contemplated

47. The New ACSM Exercise Preparticipation Health Screening Recommendations
Recognize that the hazards of exercise-related cardiovascular events may more likely be reduced by careful attention to a safe and effective exercise prescription that:
Addresses FITT-VP (frequency ,intensity, time, type, volume, progression) that incorporates a progressive transitional phase during which exercise duration and intensity are gradually increased
Advocates appropriate warm-up and cool-down
Promotes education of warning signs/symptoms
Encourages sedentary people to engage in regular, brisk walking to move them out of the least physically fit, least physically active cohort
Counsels physically inactive individuals to avoid unaccustomed vigorous intensity physical activity.

48. Upcoming Publications
Medicine Science Sports & Exercise in November 2015: Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise pre-participation health screening. Med Sci Sports Exerc, 2015; 47(11):
ACSM’s Guidelines for Exercise Testing and Prescription, 10th Edition, 2017

49. -Q and A?